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Download MRI Scan - Houston MRI
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Facility: MRN: DOS: Referring: Radiologist: Delivery: MRI PATIENT HISTORY FORM Patient Name: ____________________________________________________________ Date: ___________________ Date of Birth: __________________________ Height: _________________ Weight: ____________________ Type of Exam: ______________________________________________________________________________________ When is your next follow-up appointment with your doctor? ________________________________________________ Describe your symptoms for today’s visit: ________________________________________________________________ __________________________________________________________________________________________________ Were you injured? Yes No If yes, when? ______________ How (enter details)? _________________________ __________________________________________________________________________________________________ Have you had any surgery relating to this area? Yes Have you had other surgeries? Yes No No If yes, when? ____________________________________ If yes, what type and when? _____________________________________ __________________________________________________________________________________________________ Have you had any previous imaging studies related to today’s procedure? Yes No If yes, please list type of study, date, and location: _________________________________________________________ Are you currently taking or have you recently taken any medications? Yes No If yes, please list: ____________________________________________________________________________________ Do you have any allergies? Yes No Are you allergic to contrast used for MRI’s? Yes No If yes, please list: ____________________________________________________________________________________ Do you have or have you had any of the following: AIDS or HIV Anemia Asthma Cardiac problems Grand Mal Seizures Cancer Yes Yes Yes Yes Yes Yes No No No No No No Diabetes Yes No Liver Disease Dialysis Yes No Mononucleosis Hepatitis Yes No Sickle Cell Anemia Hypoglycemia Yes No Stroke Kidney Disease Yes No Ulcers Type: __________________________________ Yes Yes Yes Yes Yes No No No No No Please list any other medical conditions not listed above: __________________________________________________________________________________________________ FEMALE PATIENTS ONLY I am pregnant (or may be) I use an IUD I am breastfeeding Yes No Yes No Yes No Onset of last menstrual period _____/______/_____ I have had a hysterectomy Yes No I am postmenopausal Yes No Patient Signature: _________________________________________________________ Date: _______/______/______ Facility: MRN: DOS: Referring: Radiologist: Delivery: MRI SAFETY CHECKLIST AND PATIENT CONSENT FORM PATIENT NAME Patients: Height: PATIENT ID # Weight: Magnetic Resonance Imaging (MRI) provides your doctor with the latest technology available for imaging soft tissue of the body. MRI utilizes a strong magnetic field and radio frequencies, both of which have, as of yet, not proven to exhibit any long-term effects. Patients with cardiac pacemakers cannot undergo an MRI. Patients who have had surgery to implant other metal devices in the body may be able to safely have an MRI if they do not have ferromagnetic devices placed at critical locations. Patients exposed to metal grinding may have metal in their eyes. An x-ray may be necessary to detect the location of metal objects in the body. Special attention must be given to possible magnetic sensitive devices that may be placed within the body. Please answer the following questions: Yes No Are you 60 years, or over? For contrast studies, if yes, current lab report needed and Rad approval Yes No Do you have a pacemaker? Yes No Do you have metal aneurysm clips? Yes No Have you ever had metal in your eyes? Yes No Have you ever been injured by shrapnel, BB, bullets, pellets, or any other pieces of metal that are still present in your body? If yes, did a doctor get it all out? Yes No Do you have any pins, screws, wires, metal rods or plates still present in your body? If yes, explain what, which one, and location? Yes No Have you ever had head, eye, ear or heart surgery? If yes, where, when, and what kind of surgery? Yes No Are you claustrophobic? If yes, have referring physician order medication Yes No Are you pregnant, or is there a chance that you could be pregnant? (No IV contrast if pregnant) Yes No Are you breast feeding? (If breast-feeding, IV contrast patient must wait for 24 hours after) Yes No Moderate to end stage kidney/liver disease? (If yes, we cannot administer contrast) Yes No History of Hypertension? For contrast studies, if yes, current lab report needed and Rad approval Yes No History of Diabetes? For contrast studies, if yes, current lab report needed and Rad approval Yes No Have you had any X-Rays, Cat Scans, MRI’s related to the exam ordered? If yes, these films must be brought with you on the day of your exam Please place a check mark by the following items that apply to you. Aortic, carotid or arterial clips Hearing aids Artificial heart valve Inner ear surgery Artificial eye or limb Insulin or infusion pumps Brain surgery Intrauterine Device (IUD) - contraceptive Bone pins, screws, or joint replacement Neurostimulators Bridge work, dentures or partial plates Permanent cosmetic eye lining or tattoos Carotid clips Prosthesis (eye, penile, etc.) Cochlear or inner ear implants TENS unit Ear shunts Wire mesh, wire sutures, staples Electronic monitoring devices Bone growth stimulators Harrington (spinal) rods Any implant held in place with a magnet Arterial or venous catheters I have reviewed the above list and have informed the staff of scheduled facility of any possible metal within my body. I understand the risks and hazards associated with inaccurate information. The MRI exam may require an intravenous injection of contrast or medication. The introduction of contrast or drugs into the body, rarely cause mild to severe reaction. Your signature indicates that you understand the above mentioned information and all your questions have been accurately answered and that you are giving our facility consent to perform an MRI exam, including the possible injection of a contrast agent and/or medication as deemed necessary by the radiologist. Patient Signature: Date: Medical Staff Signature: Date: (or legal guardian if minor)
